How would one alter therapy in a transplant-ineligible AL amyloidosis with less than a complete response to six cycles of Dara-CyBorD?

If the patient has achieved deep VGPR (but perhaps not CR due to interference of dara), it is probably reasonable to continue dara maintenance as per ANDROMEDA as long as the patient is also clinically improving. If the response has not reached this level or the patient has not had evidence of improvement/or has had worsening organ involvement, I would consider switching regimens.

If the patient harbors a t(11;14), which is present in ~50% of cases, my therapy of choice would be venetoclax or venetoclax-combination. A recent multicenter retrospective study demonstrated a VGPR/CR rate of 78% with the use of venetoclax in relapsed/refractory AL amyloidosis patients with t(11;14) translocation (Premkumar et al., PMID 33431806). My experience ha...

Since the patient has responded, I would continue therapy. I would consider either Dara monotherapy based on ANDROMEDA study or consider Dara with Vd if the patient is able to tolerate to get to a CR. If the patient is symptomatic and unable to tolerate therapy, I would consider changing treatment.